Executive Dysfunction Double-Whammy

Executive dysfunction is a symptom you may not have heard of; it’s not widely advertised, but it plagues a lot of people with both bipolar disorder and ADD. There’s more stuff online connecting it to ADD/ADHD than bipolar, but everyone I’ve chatted with online confirms having problems with cognitive functioning.

So what is executive dysfunction anyway? Wikipedia has a great article on the subject, and there’s not a whole lot I can add to that. Essentially, it’s an abnormal reduction in cognitive capacity, linked primarily to prefrontal cortex damage or underdevelopment – isn’t it great to learn that you basically have brain damage? Yeah, not so much, though now I’m super-curious as to what my brain looks like! Everyone has occasional problems with executive functioning, but it’s a lot worse for people with certain neurologically-based illnesses. The resulting issues, sometimes called dysexecutive syndrome, include difficulties with organizing, focus, memory, impulse control, and goal-directed behavior. The latter is especially problematic when manic, since increases in goal-directed behavior are typical, particularly for me. That means that not only am I driven to do more stuff, I also don’t do it as well as I might under other circumstances. Cue massive problems with task completion and time management…

I also found a good write-up on related ADD symptoms from the perspective of a developmental impairment, which can result in people being labeled as lazy or incompetent when they really just lack the skills to perform to normal standards. This article has a nice description of the problem behaviors. I really relate to all the issues related to activation, problems with shifting focus, all the emotional regulation problems, the effort-related challenges with sleep in particular (one of the surprise benefits of Lamictal was elimination of these problems!), and action with respect to regulating the pace of my work.

If you prefer a more academic view of issues with executive dysfunction as relates to bipolar disorder, there are a slew of Medline abstracts of studies on the topic. So it’s not an unknown issue, but rather something you might not hear about. In practice, mental health professionals always seem to focus on the primary symptoms of depression and mania to the exclusion of the persistent problems with executive dysfunction, which can actually have a bigger impact on day-to-day living (in my opinion, having continually struggled with these issues when not plagued by mood swings) and are severely exacerbated by mood episodes.

OK, so my brain is just plain shrunken and atrophied when it comes to the parts that control executive function. That’s massively disappointing, especially for people who are otherwise really, really smart. Ego-wise, that really smarts. (Yeah, bad pun, but I couldn’t resist!) Another worrisome aspect of this is that for people with bipolar disorder, it often leads to employment problems (per one of the Medline abstracts) because these challenges are so pervasive and have such a strong effect on work tasks. On the other hand, there’s a bit of good news: usually adults with ADD have less problems with this over time because they learn compensatory strategies and as children, their brains are simply maturing more slowly – up to 30% more slowly. I was actually told once that even if I had ADD, I didn’t need treatment because I had learned to compensate. That wasn’t at all true, except for the learning to compensate part, and that was mostly just working about three times harder than everyone else to achieve the same results. In fact, my work habits were so overdeveloped that once I was actually treated for ADD, I really outshone everyone else because the only way I knew how to work was to an extreme.

The benefits of my medications aren’t limited to just controlling attention problems and reducing mood episodes in severity and frequency. They can also help attenuate reduced cognitive function. Since getting to an effective therapeutic level on mood stabilizers, I am no longer having the problems I used to with sleep. I am somewhat better about getting started on tasks and organizing them effectively, though really, a lot of that has to do with extensive practice. The meds do seem to reduce my persistent indecision about where to start on tasks because prioritizing is so hard for me. Obviously the emotional problems are much, much better, and my ADD meds make a huge inroad on the issues with focus. Regulating my work pace is actually much better as well, though I’ve always attributed that to mood swings – I work (very) fast when manic, and (very) slowly when depressed. Now that I’m mostly stable, I work at a pretty good and consistent clip. It was one of the biggest areas of improvement for me, besides the relief from depression.

I’m curious what other people have encountered with respect to executive dysfunction. I seem to be fairly lucky with respect to minimal memory issues because although my short-term memory has never seemed particularly good, I have amazing recall on weird little details – but perhaps that’s symptomatic too? I really wouldn’t know how my memory compares to “normal” because it just is what it always has been, like so many other things that I can’t really evaluate effectively.

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12 thoughts on “Executive Dysfunction Double-Whammy”

For me, it has always been memory. Short term memory, to be precise. It’s interesting the way my brain files things. Consider my brain to be a computer. When a process is open, like this page for instance, it does not exist on the hard drive (long term memory), but as a process running on the RAM (short term memory). Certain portions of it stored in a little file, unbeknownst to many of us, and often are wiped clean when we do a “erase history” command. Now, think of it as this. My RAM is usually pretty small, meaning I have a difficult time multitasking without using a lot of system resources. Sometimes, things just close down because they crashed. There wasn’t enough memory for it. But, that little shred gets stored into my long term memory. If I hunt hard enough, I can find that shred and make a recall of what I was working on. If not, then it’s lost.

My short term memory was bad as a child, but my long term memory is fantastic – when there weren’t any drugs or alcohol involved. With my medications, it’s gotten worse.

Where I see problems the most is in sensory integration. Loud noise is often overwhelming, and can trigger panic attacks. I am am especially sensitive when it comes to tactile. However, I cannot get enough pressure, compression, and touch. So, there is some avoidance, and some seeking when it comes to sensory input. It’s as if my brain sometimes receives information from my senses and does not know how to process it, and then what to do with it. Sensory multitasking is the most difficult. For instance, I can listen to someone and type at the same time. However, I cannot read and listen to someone at the same time. And, I can usually keep up with two conversations at once. But visual multitasking is difficult. I am very careful crossing a street, especially when cars are moving around me. But, my peripheral vision is so powerful, that I know which student is standing beside me while I’m working, without them even saying a word.

I tend to connect a lot of memory issues (correctly or not) to ADD and/or extended cannabis use. I have something I call the “vortex” where if I get up to do something, as soon as I start moving toward it, I would pass through the vortex, forget what I was going to do and have to physically rewind – go sit back down – to retrace my thoughts. It’s super-frustrating and used to happen several times a day, almost every time I would try to change tasks like that. As soon as I started ADD meds, the vortex only opened up maybe once a week! Amazing.

I also have massive problems with distractability related to sensory stimulus, but that’s also more related to ADD than bipolar. I should write a post on what it’s like to be distracted to the point that it’s distressing, since a lot of people don’t seem to understand that’s what ADD really is – a disabling level of distractedness.

I somehow doubt that extended cannabis use did it, although you might be correct. It’s hard to tell. I know a wealth of people who went through periods of time where cannabis was a daily thing, and they are well. They have incredible memories.

However, again, hard to tell. There is only one example I can think of where there was not another chemical agent involved (alcohol, medications, pills, etc). But, his memory has always been his greatest asset, so . . . inconclusive at best.

I attribute some of mine to extended alcohol use. I’ve seen it in my mother. She forgets things in her long term memory instead, opposite of mine.

As for the getting up to do something and then forgetting, I’m constantly doing that. I’ll go downstairs with three tasks in mind. One, using the bathroom, is obvious. Two, I’m down there to get something. And three, I stand there. I roam from room to room, looking for a cue. Or sometimes, I just forget altogether and find myself remembering several minutes later.

I have to retrace thoughts a lot. But, I’ve never really had too much difficulty with attention to the immediate thing in front of me. Just the short term memory of it. I take a lot of notes in seminars. Writing things down helps me. If I can see it, constantly see it in my visual field, it gives me a physical memory. I guess that’s why I keep post-it notes everywhere and long winded journals, huh?

I have major problems with this–in fact, I’d consider it one of my biggest problems. I asked my doc if I had ADD once and he said no, and attributed the executive dysfunction problems to the fact that I had been so mentally ill for so long that I had never really developed these skills.

It can be really, really difficult to identify the causes of executive dysfunction in “complex” cases. For me, it was apparent that some of the problems were related to bipolar when the treatment unexpectedly (to me) improved several of those symptoms. ADD meds made really dramatic improvements in a number of departments (blog post to come), but being diagnosed with ADD first probably delayed my bipolar diagnosis by quite a few years.

Lets see with me I can not sit and watch a tv show if there are other people talking or other distracting noises.I have a problem with knowing what to do first. Like around my house I get overwhelmed because I do not know what I should do first so I can sit and stress over this and get nothing done at all. My memory is awful. I believe it has a lot to do with the mental hospital over medicating me and sending me home to where I was slobbering and seeing monkeys in my living room. My long term memory has been affected horribly. I have lost a lot of memories of my children growing up. My short term is horrible as well.

I read an article today that puts a label to what you’re describing memory wise, which I suffer from as well. Working Memory Deficit. Just like you I remember weird random stuff that will completely amaze my friends (who think I have this great memory) but then I can’t remember little things like why I entered a room or what I was just about to type (just happened lol).

Thanks for your post I really connected with it. I’ve only been diagnosed with ADD not Bi-Polar but it still really hit home.